To 'Phaco'
or
Not?
To the Editor.\p=m-\Thephacoemulsification procedure has been available for cataract surgery in this country for nearly 20 years. During this time there have been several waves of popularity for the procedure. At present, we seem to be riding the crest of another of these waves, or so we are told. There have been major developments in equipment, instrumentation, and pharmaceutical agents intended to improve the outcome and ease of performance of this procedure. In addition, the procedure itself has been modified numerous times. Intraocular lenses have also been modified into oval shapes that will slip through a smaller incision. Foldable lenses of soft materials are also available to slip through a phaco incision. Many courses are taught by the masters throughout the United States on conversion to phaco. In addition, on at least a weekly basis, we receive slick throwaway tabloids containing information on surgical procedures, instrumentation, and intraocular lenses, many of which pertain to phacoemulsification. After 20 years, what has been the result of all of these factors, including the millions of dollars spent on promo¬ tion? Currently, phacoemulsification is the procedure of choice for 25% to 30% of the ophthalmic surgeons in the United States. Extracapsular cataract surgery, intraocular lens implantation, and argon trabeculoplasty have all gained almost universal acceptance among ophthalmic surgeons in a much shorter period. What is the reason for this discrepancy in acceptance? Could it be related to the difficulty in performing the procedure, the complication rate, or the overall surgical success rate? We do not have an answer.
We do know, however, on the basis of incomplete surveys published in throwaway journals, that high-volume sur¬ geons are most likely to use phacoemulsification as their procedure of choice. We also know, on the basis of the In¬
spector General's recent survey of cataract surgery in the
United States, that the results of surgery performed by high-volume surgeons are more likely to be unsatisfactory than those performed by the general ophthalmologist. Is there a correlation between these two findings? Again, we have no answers. Cataract surgery is the most frequently performed oper¬ ation in the United States. Is phacoemulsification the pro¬ cedure of choice for restoration of vision for patients with cataracts? Does the patient who undergoes phacoemulsifi¬ cation for a cataract have a greater risk of complications than one who undergoes standard extracapsular surgery? There are many attractive features of phacoemulsification, but the primary consideration should be whether the patient is better served by this procedure and, if so, why it has not been generally accepted among the community of
ophthalmic
surgeons.
For this reason, I propose that a national collaborative study be developed to evaluate the relative efficacy of these
Downloaded From: by a Monash University Library User on 01/16/2018
two alternative surgical procedures for patients with cata¬ racts. We all know how valuable these types of studies have
been in guiding ophthalmic therapy. Probably none would have an impact on a greater number of patients than this study would. John M. Hattenhauer, MD Wausau, Wis
Sports Vision and Vision Training: Myth or Reality? To the Editor.\p=m-\Thereis a rising interest in sports vision. Articles describing the visual abilities in athletic performance are frequent. In the field of sports vision, there is a great possibility of misinterpreting the results of ocular examinations owing to our eagerness to be involved and prescribe answers to a new field of endeavor. Financial gain
precede modest, and may
or
follow
our
our efforts. Therefore, we should be interpretations should be controlled by
double-masked studies. Instruments that test and develop saccadic fixation and dynamic vision are worthwhile, but some skepticism involving the effectiveness of visual training will arise unless controlled studies are conducted. I hope such studies can be pursued by a joint effort monitored by the American Academy of Ophthalmology and the American Academy of Optometry. Perhaps this joint effort could be controlled by the National Institutes of Health. As previously demonstrated in the study of dyslexia and learning disabilities, it would be tragic and serve no useful purpose if our efforts to study sports vision ran separate ways. At a time when our professional worlds are subject to critical observation by politicians and our own profes¬ sional bodies, it is imperative that we join in a combined effort of research. It would be well to take heed before we proceed individually in this interesting field of endeavor. Herman K. Goldberg, MD Baltimore, Md Orbital Carcinoid Tumor
To the Editor.\p=m-\Wehad the opportunity to review representative slides from the exenteration specimen kindly sent to one of us (R.L.F.) by Dr Bullock from the tumor he and his colleagues1 interpreted as a "primary orbital neuroblastoma." On review of the slides, all four of us favored the diagnosis of orbital carcinoid tumor. By light microscopy, the tumor exhibited all four main patterns described previously in cases of carcinoid tumors: pattern A (solid basaloid lobules), pattern B (trabecular or cordlike), pattern C (tubular or rosettelike), and pattern D (mixed).2 The tumor also lacked the fine fibrillary background (neuropil) that is frequently observed in cases of neuroblastoma.3 We decided to study the tumor using the Krystalon procedure used by one of us (H.B.). Portions of the section from the exenteration specimen containing tumor tissue were
or
Not?
To the Editor.\p=m-\Thephacoemulsification procedure has been available for cataract surgery in this country for nearly 20 years. During this time there have been several waves of popularity for the procedure. At present, we seem to be riding the crest of another of these waves, or so we are told. There have been major developments in equipment, instrumentation, and pharmaceutical agents intended to improve the outcome and ease of performance of this procedure. In addition, the procedure itself has been modified numerous times. Intraocular lenses have also been modified into oval shapes that will slip through a smaller incision. Foldable lenses of soft materials are also available to slip through a phaco incision. Many courses are taught by the masters throughout the United States on conversion to phaco. In addition, on at least a weekly basis, we receive slick throwaway tabloids containing information on surgical procedures, instrumentation, and intraocular lenses, many of which pertain to phacoemulsification. After 20 years, what has been the result of all of these factors, including the millions of dollars spent on promo¬ tion? Currently, phacoemulsification is the procedure of choice for 25% to 30% of the ophthalmic surgeons in the United States. Extracapsular cataract surgery, intraocular lens implantation, and argon trabeculoplasty have all gained almost universal acceptance among ophthalmic surgeons in a much shorter period. What is the reason for this discrepancy in acceptance? Could it be related to the difficulty in performing the procedure, the complication rate, or the overall surgical success rate? We do not have an answer.
We do know, however, on the basis of incomplete surveys published in throwaway journals, that high-volume sur¬ geons are most likely to use phacoemulsification as their procedure of choice. We also know, on the basis of the In¬
spector General's recent survey of cataract surgery in the
United States, that the results of surgery performed by high-volume surgeons are more likely to be unsatisfactory than those performed by the general ophthalmologist. Is there a correlation between these two findings? Again, we have no answers. Cataract surgery is the most frequently performed oper¬ ation in the United States. Is phacoemulsification the pro¬ cedure of choice for restoration of vision for patients with cataracts? Does the patient who undergoes phacoemulsifi¬ cation for a cataract have a greater risk of complications than one who undergoes standard extracapsular surgery? There are many attractive features of phacoemulsification, but the primary consideration should be whether the patient is better served by this procedure and, if so, why it has not been generally accepted among the community of
ophthalmic
surgeons.
For this reason, I propose that a national collaborative study be developed to evaluate the relative efficacy of these
Downloaded From: by a Monash University Library User on 01/16/2018
two alternative surgical procedures for patients with cata¬ racts. We all know how valuable these types of studies have
been in guiding ophthalmic therapy. Probably none would have an impact on a greater number of patients than this study would. John M. Hattenhauer, MD Wausau, Wis
Sports Vision and Vision Training: Myth or Reality? To the Editor.\p=m-\Thereis a rising interest in sports vision. Articles describing the visual abilities in athletic performance are frequent. In the field of sports vision, there is a great possibility of misinterpreting the results of ocular examinations owing to our eagerness to be involved and prescribe answers to a new field of endeavor. Financial gain
precede modest, and may
or
follow
our
our efforts. Therefore, we should be interpretations should be controlled by
double-masked studies. Instruments that test and develop saccadic fixation and dynamic vision are worthwhile, but some skepticism involving the effectiveness of visual training will arise unless controlled studies are conducted. I hope such studies can be pursued by a joint effort monitored by the American Academy of Ophthalmology and the American Academy of Optometry. Perhaps this joint effort could be controlled by the National Institutes of Health. As previously demonstrated in the study of dyslexia and learning disabilities, it would be tragic and serve no useful purpose if our efforts to study sports vision ran separate ways. At a time when our professional worlds are subject to critical observation by politicians and our own profes¬ sional bodies, it is imperative that we join in a combined effort of research. It would be well to take heed before we proceed individually in this interesting field of endeavor. Herman K. Goldberg, MD Baltimore, Md Orbital Carcinoid Tumor
To the Editor.\p=m-\Wehad the opportunity to review representative slides from the exenteration specimen kindly sent to one of us (R.L.F.) by Dr Bullock from the tumor he and his colleagues1 interpreted as a "primary orbital neuroblastoma." On review of the slides, all four of us favored the diagnosis of orbital carcinoid tumor. By light microscopy, the tumor exhibited all four main patterns described previously in cases of carcinoid tumors: pattern A (solid basaloid lobules), pattern B (trabecular or cordlike), pattern C (tubular or rosettelike), and pattern D (mixed).2 The tumor also lacked the fine fibrillary background (neuropil) that is frequently observed in cases of neuroblastoma.3 We decided to study the tumor using the Krystalon procedure used by one of us (H.B.). Portions of the section from the exenteration specimen containing tumor tissue were
